Synopsis : Reviews present compelling evidence increased physical activity and cardio-respiratory fitness help prevent or delay T2D in people with pre-diabetes and significantly improve outcomes in those living with diabetes.

Main Document

The state in which some but not all of the diagnostic criteria for diabetes are met. It is often described as the gray area between normal blood sugar and diabetic levels. Before people develop type 2 diabetes, they almost always have "pre-diabetes" - blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. Progression from pre-diabetes to type 2 diabetes isn't inevitable. With healthy lifestyle changes - such as eating healthy foods, including physical activity in your daily routine and maintaining a healthy weight - you may be able to bring your blood sugar level back to normal.

With projections that diabetes-related healthcare costs will rise to $595 billion annually in the U.S. by 2030, a series of research reviews published in the journals US Endocrinology and European Endocrinology underscore the potential for inexpensive low-cost physical activity and diet interventions to augment current therapeutic approaches in managing type 2 diabetes (T2D).

The reviews, presented today at an expert panel meeting in Washington, DC, present compelling evidence that increased physical activity and cardio-respiratory fitness help prevent or delay T2D in people with impaired glucose tolerance (pre-diabetes) and significantly improve outcomes in those living with the disease. Other findings from the large scientific reviews document the value of relatively small changes in energy intake and expenditure in combating obesity and indicate that low-calorie sweeteners may have advantages for glycemic control and weight management. Further, a comprehensive review on the role of sugars in diabetes reveals that excess calories, not fructose-containing sugars, may be the main culprit in the development of metabolic syndrome, and that fructose intake at moderate levels is not directly related to adverse metabolic effects and may provide a glycemic benefit at small doses. Touch Medical Media, publisher of the journals, hosted the expert panel meeting.

Matthew Goodwin, Business Unit Director for Touch Medical Media's Endocrinology Division, said, "Around the world, diabetes is a costly condition and given the increased prevalence of the disease, treating diabetes only through medical interventions is not sustainable. That is why the journals US Endocrinology and European Endocrinology have taken on this issue and are featuring new findings on low-cost non-medical interventions that can be readily adopted to augment current therapeutic approaches in managing diabetes."

The Role of Fructose-Containing Sugars in Diabetes

Examining the role dietary sugars may play in the development of obesity and diabetes, an extensive review co-authored by John L. Sievenpiper, MD, PhD, University of Toronto, finds no consistent evidence that at moderate doses fructose, sucrose, or high-fructose corn syrup are directly related to the development of diabetes and other cardio-metabolic diseases, while citing a potential cause for concern when fructose is consumed at high doses or contributes excess energy to diets. The paper further cites findings from systematic reviews and meta-analyses of controlled feeding trials, which show that small doses of fructose at a level obtained from fruit may provide a benefit for glycemic control. To answer the question of why there is so much conflicting data on the link between fructose-containing sugars and the epidemic of diabetes, the paper notes much of the available data come from low-quality observational studies, animal models, and overfeeding (hyper-caloric) trials featuring high consumption levels whereas large prospective cohort studies do not show a consistent relation between fructose-containing sugars and weight gain or diabetes risk. Similarly, the review notes that while significant associations have been shown comparing the highest with the lowest intake levels of sugar-sweetened beverages (SSBs), the associations are small and not observed at moderate consumption levels. Explaining that many of the metabolic consequences of a diet high in fructose-containing sugars can also be observed in those consuming high-fat diets, the paper suggests SSBs may be a marker for an overall unfavorable Western dietary pattern and that excess calories may be the main culprit in the development of metabolic syndrome.

Assessing the Role of Low-Calorie Sweeteners in Diabetes Management

Because added sugars are a source of increased carbohydrate intake, a paper by Craig A. Johnson, PhD, Brian Stevens, BSc, and John Foreyt, PhD examined the benefits of replacing added sugars with low-calorie sweeteners (LCS), which contain fewer calories and do not raise blood glucose levels. Based on a review of multiple studies, the reviewers conclude that LCS can help improve oral hygiene and dental care and is a viable way for individuals who do not have T2D to manage reactive hyperglycemia by preventing the excessive sugar intake that can lead to increased sugar secretion. The reviewers also document the safety of LCS for the prevention and treatment of diabetes and weight loss, reporting that low-calorie sweeteners have no effect on insulin and hormone secretion and have not been shown to increase appetite. Moreover, the researchers document the findings from randomly controlled trials in humans that suggest the use of LCS may increase adherence to weight loss regimens and improve bodyweight and weight loss maintenance over time. Based on these findings, the researchers conclude that LCS can serve an important role in diabetes prevention and management and offer a practical method for promoting a reduction in caloric intake.

Role of Physical Activity and Cardio-respiratory Fitness in T2D Prevention and Treatment

In light of a steep inverse relationship between physical activity and cardio-respiratory fitness and deaths in type 2 diabetes patients, independent of weight status, a paper by Carl J. Lavie, MD, Medical Director of the John Ochsner Heart and Vascular Institute, cites concrete evidence for making physical activity an integral part of a patient's medical treatment through strategies such as the Exercise Is Medicine®, a program encouraging healthcare providers to assess and review each patient's activity levels at every visit. Specifically, the paper associates low physical activity, low cardio-respiratory fitness, and obesity with a higher risk for the development of T2D, poor glycemic control and greater cardiovascular mortality risk in individuals with T2D. The review also finds that physical activity and cardio-respiratory fitness improve glycemic control, insulin action, fat oxidation and fat storage in muscle, suggesting that exercise itself is an effective treatment as well as a potential preventative for T2D that could significantly reduce the direct and indirect medical costs of treating T2D in the U.S. Among the evidence cited, a study of 523 people with impaired glucose tolerance showed that adding physical activity along with dietary changes reduced the overall incidence of T2D by 58 percent.

Applying the Principle of Energy Balance to Prevent Weight Gain

A review led by James O. Hill, PhD, Anschutz Health and Wellness Center, explores the physiologic processes underlying energy balance, which combines food intake, energy expenditure through physical activity, and energy (fat) storage, to explain the obesity epidemic in an increasingly sedentary population. Using the concept of "regulated" and "unregulated zones" of energy balance, Hill explains how interventions that focus solely on caloric restriction produce an "unregulated zone" of energy balance, which triggers the body's natural defenses toward preserving existing body weight, including increased hunger and a drop in resting metabolic rate (RMR). However in most people, relatively small changes in energy intake and expenditure can arrest weight gain while keeping the body in a "regulated zone" of energy balance. By increasing physical activity in the population, more people will move to the regulated zone of energy balance and as a result, will have greater control over their body weight.

About US Endocrinology and European Endocrinology

Published by Touch Medical Media, US Endocrinology and European Endocrinology are bi-annual peer-reviewed journals that feature review articles, case reports, practice guides, theoretical discussions, and original research addressing the most important and salient developments in the field of endocrinology. Each edition of these journals is also replicated in full online and is free to access at www.touchendocrinology.com. The full-length video of the October 29 expert panel discussion can be viewed online starting on the morning of October 30 at www.touchendocrinology.com/ObesityPanel

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